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deviation from previous literature that did not rigorously address important biases common tothis area of research.The second aim examined how maternal migration into informal urban settlements(IUSs) in Nairobi, Kenya influenced childhood vaccination timeliness. This aim leveraged 20022018 data from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS).The primary analysis explored the impact of migration status and secondary analyses of migrantsexamined whether migrant origin or previous experience living in the IUS differentiallyinfluenced timely vaccine receipt. There was no evidence that migration status or characteristicsinfluenced vaccination timeliness in IPTW-weighted models. However, a considerable portion ofboth migrant and non-migrant children in the IUSs received their vaccinations late or not at all,indicating vaccination programs in the settlements should shift focus from simply increasingcoverage to improving timeliness.Using 2004-2018 NUHDSS data, the third aim analyzed the relationship between migrantwomen’s adaptation to living in an IUS and use of recommended childbirth services.Heterogeneity in the relationship between adaptation and childbirth care was explored bycharacteristics of the migration experience. Use of recommended childbirth services waswidespread in the IUSs but not associated with migrant adaptation. The relationship betweenadaptation and childbirth care did not differ significantly by a migration type, migration stream,migration companions, or reason for migrating.Collectively, these dissertation aims provide an in-depth analysis of the relationshipbetween migration and utilization of maternal and child healthcare services in Kenya. Findingssuggest that, in Kenya, characteristics enabling migration such as wealth and education, ratherthan the process of migration itself, drive differential healthcare use between migrants and non-xii

migrants. As the public health community works towards further global reductions in maternaland under-five mortality the populations of women and children who don’t receive adequatehealthcare must be clearly defined and targeted by outreach efforts.xiii

Chapter 1 Introduction and Research AimsAlthough the United Nations and the global public health community have identifiedmaternal and child health as key priorities, substantial international health disparities in maternaland child mortality persist.1–3 Nearly 94% of maternal deaths globally are among women livingin low- and middle-income countries with approximately two-thirds of those deaths in women insub-Saharan Africa.2 Similar global disparities exist in child mortality; children living in subSaharan Africa are 15 times more likely to die before their fifth birthday than children living inhigh-income countries.4 Many of these deaths could be prevented with access to proper medicalcare during childbirth and early childhood. In 2015, in an effort to improve the lives ofindividuals across the globe, the United Nations drafted the Sustainable Development Goals(SDGs).5 The SDGs were developed as a follow-up to the Millennium Development Goals(MDGs) to build upon the MDGs’ successes in improving global health.5 Importantly, the SDGswere developed through a consensus process that included more involvement from low- andmiddle-income countries than was present in the drafting of the MDGs.5 The SDGs provide aframework for global targets aimed at achieving important development goals ranging fromalleviating (or eliminating) poverty to increases in clean energy to health and wellbeing.5 SDGtargets 3.1 and 3.2 are particularly relevant to maternal and child health, aiming to decrease theglobal maternal mortality ratio to 70 deaths per 100,000 live births (and no country above 140deaths per 100,000 live births) and under-five mortality to 25 deaths per 1,000 live births by1

2030.1 Receipt of high quality health services throughout childbirth and childhood is critical toimproving maternal and child health and eliminating preventable mortality.2,4For women, many complications of childbirth, such as infection and severe bleeding, canbe deadly without the assistance of skilled healthcare providers in a clinical setting withappropriate supplies. Yet, childbirth without a skilled attendant and outside a health facility isstill common in many low- and middle-income countries (LMICs).2 Among children, vaccinepreventable diseases, such as pneumonia and diarrhea, are leading causes of death despite theprovision of recommended vaccines for free in most LMICs under the Expanded Program onImmunization.4 In an effort to decrease disparities in maternal and child mortality it is imperativeto understand the factors contributing to the underutilization of these lifesaving maternal andchild healthcare services. Historically the literature has explored the influence of family features,like wealth,6–10 and maternal characteristics, like education and empowerment,9–12 as drivers ofmaternal and child healthcare use. Another potential factor may be maternal migration, asresearch suggests migration influences a variety of indicators of health and healthcare utilization,including under-five mortality,13 incomplete childhood immunization,14 and antenatal care andhealth facility delivery.15This dissertation explored the influence of maternal migration on the use of maternal andchild healthcare services in Kenya. The first aim investigated the relationship between maternalmigration and the receipt of recommended childhood vaccinations using nationallyrepresentative data from the 2014 Kenya Demographic and Health Survey. The second and thirdaims examined how maternal migration into two informal urban settlements in Nairobi, Kenyaimpacted vaccination timeliness (Aim 2) and the use of childbirth services (Aim 3) using 20022018 data from the Nairobi Urban Health and Demographic Surveillance System. This2

introductory chapter discusses the country of Kenya and outlines key concepts relevant tochildhood vaccination, childbirth services, migration and health, and the informal urbansettlements of Nairobi.KenyaWith a population of approximately 54.6 million, people Kenya, located in EasternAfrica, is among the top ten most populated countries on the African continent.16 It hasdemonstrated consistently strong economic growth (5%-6% real gross domestic product growthrate since 2010) and transitioned from a low- to a middle-income economy in 2014.16,17 ThoughKenya’s economy is still primarily agrarian, its tourism and technology sectors are booming,making Kenya an important economic, technology, and travel hotspot in Africa.16,18 Thisgrowing economy has led to substantial increases in the quality of life of Kenyan residents.Kenya’s human development index (HDI, a measure that combines national-level lifeexpectancy, education, and income levels into a number ranging from 0 to 1) increased from 0.46to 0.60 between 2000 and 2019.19 However, when the level of inequality is accounted for theIHDI (inequality-adjusted HDI) shrinks to 0.44, representing a loss in development of 26% dueto intranational inequalities in life expectancy, education, and income.19 Kenya’s Gini index (ameasure of income inequality in which higher values indicate more inequality) similarlydemonstrates sizable income inequality in Kenya. At 40.8, Kenya’s 2015 Gini index was not ashigh as countries like South Africa (63.0), but was higher than other countries in eastern Africaincluding Tanzania (37.8) and Ethiopia (35.0).20 These inequalities are particularly stark whencomparing Kenya’s rural and urban populations. Urban dwellers enjoy substantially highereducation (22% of men and 19% of women have received higher than a secondary education)3

and more wealth (49% of urban households fall into the richest wealth quintile) than ruralpopulations, of whom only 7% and 6% of men and women, respectively have higher than asecondary education and a mere 5% of households belong to the richest wealth quintile. 21Kenya’s government is a presidential republic.16 Prior to 2010, political power in Kenyawas highly centralized with an unicameral National Assembly and a president who wieldedimmense authority including the ability to, at will, dismiss judges and detain citizens without atrial.16,22 In a 2010 national referendum Kenyans voted to approve a new Constitution, whichmoved power and resources away from the federal government, reinstated a bicameralparliament, created a Supreme Court, and dissolved the eight regions (Central, Coast, Eastern,Nairobi, North Eastern, Nyanza, Rift Valley, and Western) in favor of 47 counties (Figure1.1).16,22 This new governmental system was incrementally phased-in beginning with 2013county Governor elections and aiming for the new decentralized government to obtain fullauthority by 2016.22Following this decentralization of political power, in 2013 Kenya’s health system wasalso restructured and much of the authority and responsibilities for health services moved fromthe central government to the local county governments.21,23 The goal of this devolution of thehealth sector was to promote efficiency and equality in health services and reduce regionaldisparities in health outcomes.23 As an example of the stark disparities in healthcare accessbefore devolution, in 2008-2009 96.4% of women living in the Nairobi region received antenatalcare from a skilled provider (doctor, nurse, midwife, etc.) and 89.4% gave birth in a healthfacility while in the North Eastern region only 69.5% of women received skilled antenatal careand only 17.3% of women delivered their child in a health facility.24 Childhood vaccinationcoverage demonstrated similar regional inequities, with nearly 86% of children in the Central4

region receiving all basic immunizations compared to less than 50% of children in the NorthEastern region.24 After decentralization of the health sector, the central government now createsnational health policy and provides technical and capacity building support to counties, whilecounty governments are responsible for the provision of public health services and the promotionof health services utilization, including the organization of community health volunteers andcommunity health extension workers.21,23 The central government of Kenya has developed avariety of maternal and child health programs and policies designed to improve maternal andchild health and increase health service use such as the Kenya Expanded Program onImmunization, free delivery services at public health facilities, the Integrated Management ofChildhood Illness Initiative, the Community-Based Newborn Care Program, the Infant andYoung Child Feeding Program, Malezi Bora (maternal and child health and nutrition weeks heldtwice a year), and campaigns to increase the receipt of vitamin A supplementation anddeworming medications.21,25Child vaccination in KenyaChildhood mortality in Kenya has seen a striking decrease since the early 2000s, withunder-five mortality dropping from 100 to 43 deaths per 1,000 live births between 1990 and2019, though reaching the 2030 SDG target of 25 under-five deaths per 1,000 live births hasremained elusive.3,26 This decline in under-five mortality is largely the result of Kenya’simpressive improvements in vaccination coverage since the introduction of the Kenya ExpandedProgram on Immunization (KEPI), as 35% of under-five deaths in Kenya are due to diarrhealdiseases, pneumonia, and measles, all of which are vaccine preventable. 27,28 The KEPI wasinstituted in 1980 with the goal of providing vaccines that protect against tuberculosis, polio,5

diphtheria, pertussis, tetanus, and measles (the “basic” vaccination series) to the children ofKenya for free.27 Since its initiation, new vaccines have been added to the KEPI schedule whichnow includes 15 doses: one dose of Bacille Calmette- Guérin vaccine given at birth (BCG,protects against tuberculosis); three doses each of the oral poliovirus vaccine (OPV), thepentavalent vaccine (penta, includes diphtheria, tetanus, pertussis [DTP], hepatitis B [HBV], andHaemophilus influenza type b [Hib] antigens), and the pneumococcal conjugate vaccine (PCV)given at 6, 10, and 14 weeks; one dose of the inactivated poliovirus vaccine (IPV) given at 10weeks; two doses of the rotavirus vaccine (rota) given at 6 and 10 weeks, and two doses of themeasles vaccine given at 9 and 18 months (Table 1). 21,29Implementation of the KEPI has resulted in significant increases in vaccination coveragein Kenya. Coverage of the third dose of the diphtheria-tetanus-pertussis-containing vaccine(DPT3, a precursor to the pentavalent vaccine and an indicator often used to estimate vaccinationprogram performance) among children aged 12-23 months increased from 58% in 1984 to 92%in 2019.27,30 Other doses followed a similar trend with coverage of BCG increasing from 76% to95% and the 9-month dose of the measles vaccine increasing from 55% to 89% in the sameperiod.30 The proportion of children who are fully vaccinated with all recommended doses hasfollowed a similar trend. Further, receipt of all vaccines (except PCV, rota, and IPV, whichweren’t introduced until later) has continued to increase consistently over the past two decadesfrom 57% in 2003 to 77% in 2008-2009 and 79% in 2014.21 These advances are considerableand receipt of many individual doses reach the World Health Organization Africa RegionalStrategic Plan for Immunization’s goal of 90% national coverage in by 2020.31 However, DPT3coverage at the county level demonstrates less success as almost half of Kenya’s 47 countieshave DPT3 coverage below 80%, falling below the Plan’s goal of 80% coverage in all districts6

and representing important geographic disparities in vaccination coverage.31,32 Clearly, muchprogress has been made in providing immunization services to children in Kenya, but much workremains to ensure this life-saving service is available to all Kenyan children.Estimating cumulative vaccination coverage at certain age intervals (e.g., proportion ofchildren aged 12-23 months who have received DPT3) is the most straightforward and commonmanner in which researchers and public health officials estimate community protection againstvaccine preventable diseases (VPDs). However, simple coverage estimates can mask importantdelays in vaccine receipt that may result in substantial disease transmission among children whoare younger than the examined age interval and at ages when they are particularly prone to moreserious disease, hospitalization, and death. These delays leave children susceptible to VPDslonger than necessary and place communities at risk of VPD outbreaks.33,34 In an effort to betterunderstand child and community protection against VPDs researchers have begun examiningvaccination timeliness in addition to vaccination coverage. Vaccination timeliness, calculated asthe continuous measure of a child’s age at vaccine receipt, can provide a better characterizationof whether a child is delayed in receiving individual vaccines and whether a community hassufficient vaccination levels to protect against outbreaks. Using this continuous measure of age atvaccination, a particular vaccine dose is considered timely if it is received within one month ofthe date recommended by a country’s national vaccination schedule.35 Interest in estimatingvaccination timeliness has increased dramatically in the last ten years as vaccination programstransition from simply optimizing vaccination coverage to ensuring timely vaccine receipt. Theneed for an increased focus on vaccine timeliness is exemplified by Kenya, which has high levelsof vaccine coverage but only 37% of children currently aged 12-36 months received all eightbasic KEPI vaccines on time.8 This proportion masks a significant inequity in timeliness by7

urbanicity, with 48% of urban children compared to only 31% of rural children receiving allbasic vaccines on time.8 Similar to vaccination coverage, there is much work to be done todecrease disparities in vaccination timeliness in Kenya and ensure all children not only receiveeach recommended dose but receive each dose on time.Maternal childbirth services in KenyaKenya has also achieved impressive improvements in maternal mortality in the 2000swith the maternal mortality ratio declining from 678 to 342 deaths per 100,000 live birthsbetween 2003 and 2017.36 Though still well above the 2030 SDG target of 70 deaths per 100,000live births, it is clear that decreasing maternal mortality has been

indicating vaccination programs in the settlements should shift focus from simply increasing coverage to improving timeliness. Using 2004-2018 NUHDSS data, the third aim analyzed the relationship between migrant women's adaptation to living in an IUS and use of recommended childbirth services.